Internal carotid artery cavernous sinus aneurysm surgery

The cavernous sinus segment of the internal carotid artery is a segment of the internal carotid artery between the lateral ring of the internal carotid artery and the proximal ring to the proximal ring, which is about 3 cm in length (Fig. 4.4.2.7-1). An aneurysm that occurs in this segment is called an internal carotid cavernous sinus aneurysm. Its incidence accounts for about 3% of all intracranial aneurysms. The causes of aneurysm are: 1 congenital development; 2 traumatic, skull base fracture or transsphenoidal pituitary tumor resection when the artery wall is injured; 3 arteriosclerosis; 4 infectious, such as cavernous sinusitis, etc. form. Because the anatomical relationship of the cavernous sinus is complicated and there is dura mater protection on the outside, the treatment of the internal carotid aneurysm occurring in this part has direct surgery, endovascular treatment and observation, etc., and the treatment method should be determined according to the specific situation of the patient. Treatment of diseases: intracranial aneurysms Indication Internal carotid cavernous sinus aneurysm surgery is applicable to: 1. A traumatic aneurysm caused by a skull base fracture and protruding into the adjacent sinus. Once the rupture can cause fatal nosebleeds, it must be treated surgically. 2. Large or large aneurysms cause eye movement, neural crest or facial pain. 3. The aneurysm breaks into the cavernous sinus and causes the internal carotid artery-cavernous sinus fistula to undergo endovascular treatment or direct surgical treatment. 4. About 50% of the cavernous sinus segment of the internal carotid aneurysm is a small aneurysm or accidentally found without clinical symptoms, feasible endovascular treatment. 5. Infectious aneurysms should be treated with antibiotics first, then treated with endovascular or direct surgery depending on the situation. Contraindications 1. The patient is old and frail and cannot tolerate anesthesia or craniotomy. 2. The source of systemic infection is uncontrolled or the infectious aneurysm is not adequately treated with antibiotics. Preoperative preparation 1. Adequate cerebral angiography should be performed, including ipsilateral and contralateral carotid angiography and cross circulation test, ie, compression of the diseased side carotid artery during contralateral carotid angiography to observe the contralateral neck The arteries fill the diseased side of the carotid artery system through the anterior communicating artery. Similarly, during the vertebral angiography, the carotid artery of the diseased side was compressed to observe the condition that the vertebral-basal artery system was filled with the posterior carotid artery through the posterior communicating artery. 2. The internal carotid artery of the diseased side was blocked with a balloon to observe the ability to temporarily block the tolerance of the internal carotid artery. 3. Take the skull X-ray film and CT bone window to understand the skull base fracture. 4. Perform MRI to observe the thrombus in the aneurysm. 5. If arterial reconstruction is planned, it should be understood whether the bilateral radial arteries are suitable for arterial bridging by compressing the radial artery to see if the ulnar artery can adequately supply the blood flow to the hand. 6. Explain the surgical plan to the patient and family members. Temporary eye movements may occur after the operation, and the risk of surgery should be explained to the family. Surgical procedure Anesthesia and position 1. Mild hypothermic anesthesia, continuous monitoring of cerebral perfusion status. 2. Awaken as soon as possible after the operation to see if there is any paralysis of the contralateral limb. 3. Lying flat, the head turns to the opposite side 35°, the head is fixed with the Mayfield head frame, and the operating bed can be tilted left and right and back and forth to adjust the optimal viewing angle. Surgical procedure 1. Make a curved incision of the frontal sac, starting from the front of the sacral arch 2cm, and finally the hairline leading edge and 2~3cm beyond the midline. The scalp is turned forward until the gingival margin and frontal bone condyle. Retract with a spring pull hook. At this point, the upper edge of the zygomatic arch can be seen. The periosteum is cut outside the stop point of the diaphragm, drilled according to the position shown, and the bone flap is cut back and down along the dotted line with a milling cutter. At this time, be careful not to damage the dura mater. If it is worn, it should be carefully repaired to avoid cerebrospinal fluid leakage. 2. Cut the humerus and sphenoid bone under the bone window to the bottom of the skull. 2 to 3 needles are sewn on the dural to remove the anterior and middle cranial fossa. The dome and sphenoid bones were honed with a rapid grinding drill, the outer side until the outer edge of the upper iliac cleft, and the inner side of the anterior bed and the top of the optic canal were removed. If the paranasal sinus is opened, it needs to be closed. The next step should be based on the size and location of the aneurysm, such as small aneurysms, the above revealed enough; if the aneurysm is large or partial thrombus occlusion, may need to be resected or end-to-end anastomosis of the internal carotid artery, must first The internal carotid artery of the rock segment is revealed. The outer layer of the outer wall of the cavernous sinus is separated along the interface. At this time, the sharp separation is more suitable than the blunt separation. The inner layer contains the first and second branches of the oculomotor nerve, the trochlear nerve, the abductor nerve and the trigeminal nerve, and can be exposed. Aneurysm wall. 3. The location of the aneurysm determines the relationship between each cranial nerve and the aneurysm and the displacement to which: the oculomotor nerve and the trochlear nerve are usually pushed to the medial side, the abductor nerve is pushed to the outside, and the trigeminal nerve 2, 3 and The anterior portion of the half-moon section is topped or pushed outward by the aneurysm. 4. The next step is to reveal the anterior curvature of the internal carotid artery. This artery can be found between the optic nerve and the moving eye and the trochlear. Then, depending on the location of the aneurysm, it is determined from which triangular gap the aneurysm is revealed. The most commonly used is the Parkinson triangle, which is the triangular gap between the moving eye, the trochlear nerve and the first branch of the trigeminal nerve. If there is a partial thrombus in the aneurysm, a temporary aneurysm clip is used to block the proximal and distal tumor-bearing arteries before the aneurysm is separated to prevent aneurysmarterial embolization after the thrombus is detached. 5. Separate the aneurysm neck and select a suitable tumor clip to clamp it. If the neck is wide or the aneurysm is fusiform, it is usually not clipped. In this case, different methods should be used according to the specific situation. If the width of the neck exceeds 0.5 cm and the aneurysm neck has a sclerosing change, it is best to remove or isolate the aneurysm and bridge the saphenous vein or artery in the proximal and distal sides of the internal carotid artery. If the proximal or distal segmental arteries can be resected by resection or isolation of the aneurysm, end-to-end anastomosis can be performed. If the anterior curvature of the internal carotid artery is also hardened and the above-mentioned end-to-end anastomosis is not possible, only the bridge between the sacral segment and the internal carotid artery of the upper segment of the dura mater is bridged, and the end of the rock is end-to-end. The upper part of the bed is aligned with the side, so that the eye artery still has blood supply. In the above-mentioned arterial reconstruction surgery, in order to shorten the distance of the end of the internal carotid artery and to facilitate the operation, it can be performed on the outer surface of each cranial nerve. 6. If the neck of the tumor is thicker and the sclerosing changes of the neck tissue are not obvious, the segmental and anterior curvature of the internal carotid artery can be temporarily blocked, the aneurysm can be dissected, the thrombus removed, the aneurysm wall be trimmed, and heparin can be used. The liquid is flushed into the lumen, and then the tumor wall is sutured. When the last 1-2 needles are sewn, the distal and proximal arterial clips are released, and the possible bubbles are rushed out, and then sutured. 7. After the reconstruction of the blood vessel, the internal carotid artery was measured by Doppler blood flow meter. complication There are epidural hematoma, cerebrospinal fluid leakage, cranial nerve injury and cerebral ischemia.